REVIEW

Probiotics and Prebiotics: A Brief Overview

JoMay Chow, PhD*
Probiotics and prebiotics are 2 food ingredients that confer physiologic effects through the gastrointestinal tract.
Probiotics have been dened as viable microorganisms that (when ingested) have a benecial effect in the
prevention and treatment of specic pathologic conditions. These microorganisms are believed to exert biological
effects through a phenomenon known as colonization resistance, whereby the indigenous anaerobic ora limits the
concentration of potentially pathogenic (mostly aerobic) ora in the digestive tract. Other modes of action, such as
supplying enzymes or inuencing enzyme activity in the gastrointestinal tract, may also account for some of the
other physiologic effects that have been attributed to probiotics. Conversely, prebiotics are nondigestible food
ingredients that benecially affect host health by selectively stimulating the growth and/or activity of 1 or a limited
number of bacteria in the colon. The prebiotic, fructooligosaccharide (FOS), is found naturally in many foods, such
as wheat, onions, bananas, honey, garlic, or leeks. They can also be isolated from chicory root or synthesized
enzymatically from sucrose. Fermentation of FOS in the colon results in a large number of physiologic effects
including increasing the numbers of bidobacteria in the colon, increasing calcium absorption, increasing fecal
weight, shortening of gastrointestinal transit time, and possibly lowering blood lipid levels. Other effects that have
been observed in animal models include an increase in cecal weight and an increase in fecal nitrogen excretion. The
increase in bidobacteria has been assumed to benet human health by producing compounds to inhibit potential
pathogens, by reducing blood ammonia levels, and by producing vitamins and digestive enzymes.
2002 by the National Kidney Foundation, Inc.

HE NOTION that food could serve as

medicine was rst conceived thousands of
years ago by the Greek philosopher and father of
medicine, Hippocrates, who once wrote, Let
food be thy medicine, and let medicine be thy
food.1 However, during recent times, the concept of food having medicinal value has been
reborn as functional foods, a term that refers to any
food or food ingredient that may provide a health
benet beyond the traditional nutrients it contains.1 This article provides a brief overview of
probiotics and prebiotics, 2 increasingly popular
ingredients that can be found in functional foods
and dietary supplements. The review rst de-

scribes these ingredients and then explains how

they are believed to work within the human
body. Lastly, this article highlights some potential
applications for these ingredients in patients with
renal disease. For a more comprehensive treatment of these topics, the reader may consult
several other articles.2-6

Probiotics

*Research Scientist, Strategic-Discovery Research and Development, Ross Products Division, Abbott Laboratories, Columbus,
OH.
Address reprint requests to JoMay Chow, PhD, Strategic-Discovery Research and Development, Ross Products Division, Abbott
Laboratories 105670/RP3-2, 625 Cleveland Ave, Columbus,
OH 43215-1724.
2002 by the National Kidney Foundation, Inc.
1051-2276/02/1202-0001$35.00/0
doi:10.1053/jren.2002.31759

Denition and Strains

Probiotics may be dened as viable microorganisms that (when ingested) have a benecial
effect in the prevention and treatment of specic
pathologic conditions.7 The most popular
strains are represented by the following genera:
Lactobacillus, Streptococcus, and Bidobacterium (Table 1), but other organisms including enterococci
and yeasts have also been used as probiotics. Some
of these strains were chosen based on selection
criteria8 that are believed to be important for
efcacy such as origin of strain, in vitro adherence
to intestinal cells,9-11 and survival during passage
through the gastrointestinal tract.12-16 However,

76

Journal of Renal Nutrition, Vol 12, No 2 (April), 2002: pp 76-86

PROBIOTICS AND PREBIOTICS

Table 1. Microorganisms That Are Commonly
Regarded as Human Probiotics
Species
Bidobacterium bidum
Bidobacterium breve
Bidobacterium infantis
Bidobacterium longum
Enterococcus faecalis
Enterococcus faecium
Lactobacilus acidophilus
Lactobacilus casei Shirota
Lactobacilus delbrueckii subspecies bulgaricus
Lactobacilus GG
Lactobacilus johnsonii
Lactobacilus reuteri
Lactobacilus rhamnosus
Lactobacilus plantarum
Lactobacilus salivarius
Saccharomyces boulardii (yeast)
Streptococcus thermophilus

whether these properties are absolutely required

for clinical efcacy has not yet been clearly established in the literature.
Enterococci such as Enterococcus faecalis and Enterococcus faecium are common inhabitants of the
human gastrointestinal tract. Both species have
been used as probiotics, but their safety has been
questioned17 because they have become an increasingly important cause of nosocomial infections.18 The use of enterococci as probiotics is
discussed in greater detail later in this review.
Saccharomyces bouldardii is a nonpathogenic yeast
that is sometimes used to treat Clostridium difcile
diarrhea.19 This organism, which was originally
isolated from lychee fruit in southeast Asia, was
used to treat diarrhea as early as the 1950s. Like
other probiotic organisms, S boulardii does not
colonize the colon permanently; therefore, repeated dosings are needed to maintain detectable
levels. Based on in vitro, animal, and human
clinical studies, S boulardii is thought to eradicate
invasive pathogens by using multiple mechanisms
including microbial interactions, antisecretory effects, inhibition of toxin binding to receptors,
immunologic effects, and trophic effects on the
intestinal mucosa.20

History
The group of microorganisms most frequently
regarded as probiotics, the lactic acid bacteria, has
a long history of consumption by humans. These
bacteria, which originally served to prevent spoilage of food by undesirable organisms, were con-

77

sumed in the form of fermented milk as early as

4000 BC. The consumption of fermented milk
was rst documented in the Old Testament, and
ancient carvings indicated that humans purposely
inoculated milk with cultures to produce sour
milk as long ago as 2250 BC.21
During the modern era, consumption of fermented milk came into fashion during the early
1900s because of the efforts of Russian scientist
Elie Metchnikoff. Metchnikoff rst developed
the notion that fermented milk products might
have medicinal value. His hypothesis was based
on the observation that Bulgarian peasants, who
had extraordinary longevity, also happened to
consume sour milk.
The consumption of fermented milk products
fell out of fashion shortly thereafter, but growing
concerns over antibiotic resistance and food safety
have brought probiotics back into the spotlight of
both animal and human health. Scientists from
the US Department of Agriculture, in collaboration with Milk Specialties Bioscience (Dundee,
IL), developed PREEMPT, a novel probiotic
product for use in chickens. PREEMPT consists
of 29 different microorganisms isolated from the
intestines of adult birds and was the rst commercial dened competitive exclusion culture
against Salmonella colonization in poultry.22 This
product, which is sprayed on newly hatched
chicks, was approved by the US Food and Drug
Administration and introduced in 1998.

Safety
Overall, traditional dairy strains of probiotic
bacteria, particularly those belonging to the Lactobacillus and Bidobacterium genera, are considered to be of low pathogenic potential when
given to healthy humans.23,24 Even after many
years of use, probiotics have been linked to only
1 clinical infection.25 In this case, a purulent
viscous uid specimen was aspirated from a hepatic abscess in a 74-year-old woman with a
history of hypertension, noninsulin-dependent
diabetes mellitus, mild abdominal discomfort, and
mild fever. The aspirate contained virtually a pure
culture of gram-positive coccobacilli. Results
from enzymatic testing and molecular analysis
(polymerase chain reaction assay and pulsed-eld
gel electrophoresis) of the culture aspirate were
indistinguishable from those of Lactobacillus strain
GG. An interview with the patient revealed that
she had been ingesting approximately 0.5 L Lac-

78

JOMAY CHOW

tobacillus GG dairy drinks daily for 4 months

before the onset of symptoms in an attempt to
relieve abdominal discomfort.
In fact, aside from the involvement of some
lactobacilli species in dental caries, microorganisms belonging to the Lactobacillus and Bidobacterium genera, whether considered probiotics or
not, have been largely regarded as nonpathogenic.17,26,27 Members of both genera inhabit the
human large intestine at concentrations exceeding 109 colony-forming units per gram dry feces.28 However, these organisms occur infrequently in human infections, particularly when
compared with members of the genus Bacteroides,
which also inhabit the human digestive tract. For
instance, Moore et al29 isolated anaerobes from
81 consecutive clinical specimens that were submitted to their laboratory for culture. From these
specimens, they cultured a total of 144 isolates, of
which 33.3% were identied as members of the
Bacteroides genus. In contrast, only 2.1% of the
isolates were identied as members of the Bidobacterium genus. Lactobacilli were not listed
among the isolates, but some of the unidentied
gram-positive nonsporing rods, which made up
2.1% of the total isolates, may have belonged to
this genus. In a subsequent study, Saxelin et al30
collected blood culture isolates over a 4-year
period in Finland from cases of bacteremia. Of
the 3,317 isolates that were detected, only 8 were
identied as lactobacilli.
Although probiotic organisms have a long
track record of safe consumption, a number of
circumstances warrant caution when choosing a
particular strain. First, the species of probiotic
should be considered. With the exception of
some lactobacilli, organisms belonging to the Lactobacillus or Bidobacterium genera are very rarely
pathogenic,31 despite their ubiquitous presence in
various body sites. Nevertheless, an extensive
search of the literature suggests that certain species, such as Lactobacillus rhamnosus or Lactobacillus casei subspecies rhamnosus,32-37 Lactobacillus
plantarum,33,36-38 and Bidobacterium dentium39-41
(formerly known as Actinomyces eriksonni or Bidobacterium eriksonni), may have greater pathogenic potential than others.42
Organisms other than lactobacilli and bidobacteria have also been used as probiotics,
and these other organisms should be examined
closely for potential pathogenicity because
closely related strains may be known patho-

gens. As an example, enterococci have been

implicated as the primary pathogen in a variety
of infections including enterococcal meningitis, endocarditis, bacteremia, and urinary tract
infections.17 Hence, the use of enterococci,
namely E faecium and E faecalis, as probiotics
have fallen into disfavor because they have
been found to be the third leading cause of
nosocomial infections in the United States43
and because they have acquired resistance to a
large number of antimicrobial agents including
vancomycin.18 Perhaps the most worrisome
development regarding this genus was the acquisition of vancomycin resistance and the possibility that the resistance genes could be transferred to other gram-positive pathogens such as
Staphylococcus aureus.18 Fortunately, the probiotic E faecium strain SF68 is sensitive to vancomycin, ampicillin, amoxicillin, chloramphenicol, and vibramycin; however, it is resistant to
a large number of antimicrobials including
erythromycin, gentamycin, neomycin, streptomycin, clindamycin, cloxacillin, cephuroxim,
colicin, nitrofurantoin, nalidixic acid, and trimethoprim-sulfamethoxazole.44
Qualitative data collected from case studies
suggest that lactic acid bacteria can act as opportunistic pathogens by producing infections almost
exclusively in debilitated patients.45 Thus, the
relative risk to the patient should be assessed
before the administration of probiotics. Patients
who are immunocompromised because of extreme age (infant or elderly), use of therapeutics
(eg, immunosuppressive agents), or presence of
underlying disease may be at greater risk for
infection by lactic acid bacteria.45
Additionally, patients who undergo dental
procedures, have periodontal disease, or have
underlying structural heart disease seem to be at
increased risk for endocarditis.45 Nonetheless, the
risk of potential infection because of probiotic
therapy should be weighed relative to the risk of
side effects because of the administration of traditional medications, many of which are known
to produce adverse effects.
The probiotic, Lactobacillus acidophilus strain
NCFM, has been fed to a number of hemodialysis
patients with end-stage kidney disease without
adverse effects.46,47 However, other members
of the Lactobacillus genus including unspecied
strains of L acidophilus48 and L rhamnosus33,49,50

79

PROBIOTICS AND PREBIOTICS

have been isolated from the peritoneal uid of

patients with peritonitis who were undergoing
continuous ambulatory peritoneal dialysis. Each
of the isolates was detected only after the patients
had been treated with multiple antibiotics including vancomycin, and all of the isolates displayed
resistance to this particular antibiotic. No attempts were made to identify the source of the
lactobacilli, but the investigators33,48,50 assumed
that the organisms originated in another body site
such as the gastrointestinal tract.

Mechanisms of Action
The mechanisms by which probiotics exert
biological effects are still poorly understood, but
the nonspecic terms colonization resistance or
competitive exclusion are often used to explain
their mode of action. Colonization resistance or
competitive exclusion describes a phenomenon
whereby the indigenous anaerobic ora limits
the concentration of potentially pathogenic
(mostly aerobic) ora in the digestive tract.51
The concept of competitive exclusion was rst
developed during the early 1970s when it was
discovered that the administration of mixed adult
intestinal microorganisms conferred adult-type
resistance against salmonella infection to newly
hatched chicks.52 Even more striking evidence of
the protective effect of the normal intestinal microbiota comes from studies of Clostridium difcile
pseudomembranous enterocolitis in both animal
models53 and in patients who experience multiple
recurrences of diarrhea or colitis after discontinuation of successful antibiotic therapy.54-58
Some of the specic mechanisms by which the
intestinal microbiota exclude undesirable organisms are thought to include the following:59,60 (1)
production of inhibitory substances, (2) blocking
of adhesion sites, (3) competition for nutrients,
(4) degradation of toxin receptor, and (6) stimulation of immunity. Although probiotic bacteria
are thought to mediate their effects by using some
of the same mechanisms as the native intestinal
ora, probiotics may also work through other
modes of action such as supplying enzymes or
inuencing enzyme activity in the gastrointestinal
tract.59 In fact, some studies have even suggested
that probiotics, killed cells, or certain cell fractions exert antimutagenic61 or adjuvant effects,62
inuence cytokine expression,63 or inuence the
development of allergies.64

Potential Applications for Improving

Human Health
Given the wide variety of mechanisms by
which probiotics are thought to work, scientists
have proposed a variety of clinical applications for
these organisms (Table 2). Much of the past
research examined the application of probiotics to
rotavirus diarrhea or lactose intolerance, but a
number of intriguing results have also been published regarding probiotic use in antibiotic-associated diarrhea,65 Candida vaginitis,66 Clostridium
difcile,67-69 cryptosporidiosis,70 Helicobacter pylori
gastroenteritis,71 hepatic encephalopathy,72 inammatory bowel disease,73 necrotizing enterocolitis,74,75 small bowel bacterial overgrowth in
uremia,46,47,76 suppression of chemically induced
large bowel tumors,77 and urinary tract infections.78,79
A unique application for probiotics in renal
patients is the reduction of toxic metabolites,
which are generated as a result of small bowel
bacterial overgrowth during uremia.76 These metabolites are thought to be responsible for some of
the general symptoms of chronic renal failure,
such as neurologic abnormalities, and they may
also interfere with the absorption of nutrients
from the gut.80 In a pilot clinical study,47 19
patients with chronic renal failure ingested capsules containing 1 of 2 human strains of L acidophilus, strain NCFM or strain BG2F04. Each
capsule contained at least 109 colony-forming
units, and 1 capsule was taken twice daily for an
average of 76 26 days. Results showed that oral
ingestion of L acidophilus reduced the serum levels
Table 2. Potential Applications for Probiotics and
Sample References
Clinical Application

Reference

Antibiotic-associated diarrhea
Candida vaginitis
Clostridium difcile
Cryptosporidiosis
Helicobacter pylori gastroenteritis
Hepatic encephalopathy
Inammatory bowel disease
Lactose intolerance
Necrotizing enterocolitis
Rotavirus diarrhea
Small bowel bacterial overgrowth
in uremia
Suppression of chemically induced
large bowel tumors
Urinary tract infections

65
66
67-69
70
71
72
73
120
74,75
121-123
46,47,76
78
79,80

80

JOMAY CHOW

of the marker compound, dimethylamine, from

257 45 g/dL to 150 49 g/dL (P .001),
and blood nitrosodimethylamine levels decreased
from 236 69 ng/kg to 118 38 ng/kg (P
.0053). These results were subsequently reconrmed in a placebo-controlled, double-blind,
parallel study in patients undergoing hemodialysis.46

Commercial Products
Many culture-containing dairy products such
as yogurts and culture-added milks contain live
microorganisms, but these products require refrigeration and have relatively short shelf lives that
are measured in terms of weeks instead of
months. On the other hand, freeze-dried microorganisms can remain viable indenitely under
ideal storage conditions. Therefore, because it has
been assumed that viability is required for biologic activity, probiotic product forms have been
largely limited to capsules, tablets, and powders.
Even so, some commercial products, including
those in tablet and capsule forms, display a
marked discrepancy between the claimed and
actual count of viable bacteria and/or a discrepancy between the species shown on the label and
the actual species present in the product.81
A number of probiotic products are available in
the United States. As an example, Lactinex (Becton-Dickinson; Franklin Lakes, NJ), a powdered
or tabletted product consisting of a mixture of L
acidophilus and Lactobacillus bulgaricus, has been on
the market since the early 1960s. However, clinical studies suggest that this preparation was ineffective for preventing or altering the course
of enterotoxigenic Escherichia coli diarrhea in
adults82,83 and for reducing the incidence or
duration of travelers diarrhea.84 In addition, a
number of new probiotic-containing products
such as Culturelle (L GG capsules; CAG Functional Foods, Omaha, NE) and Probiotica (Lactobacillus reuteri tablets; McNeil Consumer
Healthcare, Ft Washington, PA) have been
launched during recent years. Some of these organisms have undergone extensive clinical testing.

gredient that benecially affects the host by selectively stimulating the growth and/or activity
of one or a limited number of bacteria in the
colon, and thus improves host health. At the
present time, a large number of ingredients are
known to escape hydrolysis in the small intestine,
but only 4 ingredients also meet the criteria set
forth for prebiotics in stimulating the growth of
certain bacteria: transgalactosylated disaccharides,
xylooligosaccharides, soybean oligosaccharides
and fructooligosaccharides (FOSs). This review
focuses solely on FOS because it was the rst
prebiotic oligosaccharide made available in the
United States and because much more is known
about it than other prebiotics.

Structure of FOSs
FOSs are short- and medium-length chains of
-D-fructans in which fructosyl units are bound
by 2-1 glycosidic linkages (Fig 1). Some molecules also contain glucose as the rst moiety.
These compounds occur naturally in many
foods85 including wheat, onions, bananas, honey,
garlic, and leeks, but more puried forms may
be purchased commercially. Long-chain fructan polymers, referred to as inulin (Raftiline
[DRAFTI Active Food Ingredients, Tienen, Belgium] or Frutat [Imperial-Suiker Unie, Sugar
Land, TX]), are isolated from chicory root. These
fructans can be partially hydrolyzed by enzymes
to make a type of FOS known as oligofructose
(Raftilose [DRAFTI Active Food Ingredients]).
FOSs can also be synthesized from sucrose by
using enzymes from Aspergillus niger to make
Neosugar (Actilight [Beghin-Meiji Industries,
Paris, France], Meioligo [Meiji Seika Kaisha, Tokyo, Japan], NutraFlora [GTC Nutrition, Westminster, CO]).

Prebiotics
Denition
The term prebiotic, rst coined by Gibson and
Roberfroid,5 refers to a nondigestible food in-

Figure 1. Chemical structure of Neosugar FOSs.

PROBIOTICS AND PREBIOTICS

Safety of FOSs
The US Food and Drug Administration has
not yet approved FOS as generally recognized as
safe (GRAS), but existing evidence suggests that
the government will eventually grant this ingredient GRAS status.86 As mentioned previously,
FOSs occur naturally in a wide variety of foods.
In fact, Americans consume approximately 2.5 g
of inulin and oligofructose daily (range of 1 to
4 g), mostly from wheat and onions.87 In addition, several US companies have already selfafrmed either oligofructose or Neosugar FOS as
GRAS by having an expert panel review documentation regarding the safety of this ingredient.
On a worldwide basis, NutraFlora FOS has been
incorporated into at least 500 food products. In
Japan, FOSs have been approved by the Minister
of Health and Welfare as foods for specied
health use (FOSHU) and have been included in
at least 13 products that function as table sugar.
In terms of safety, the ingestion of FOSs cause
few adverse effects, and the adverse effects are
minor in nature.88 Because FOSs possess many of
the same physiologic properties as dietary ber,
the consumption of FOSs can lead to symptoms
just like those encountered after a sudden increase
in dietary ber intake with the severity of symptoms related to intake level.88 Common symptoms include atulence, cramping, and diarrhea,
but effects are only temporary.
The safety and tolerance of FOSs were actually
measured in stable hemodialysis patients.89 Seventy-nine normally nourished, stable, anuric, adequately dialyzed, adult outpatients with endstage renal disease were randomized to 1 of 3
treatment groups in a prospective, controlled,
single-blind, parallel study. The treatment groups
included a standard medical nutritional and 2
renal nutritionals with one of the renal nutritionals containing added -carotene and FOSs. During the 3-week long study, gastrointestinal symptoms and bowel habits were recorded during a
1-week baseline period and during 2 weeks of
treatment. Subjects who were randomized to the
FOS-containing treatment ingested an average of
15.6 0.9 to 18.5 1.2 g FOSs daily, and those
in the other 2 groups did not ingest any FOSs.
Results from the study showed that the number
of instances in which gastrointestinal symptoms
required treatment was not different between the
renal nutritional without FOSs and the renal

81

nutritional with FOSs. Similarly, there were no

differences between the 3 treatment groups regarding the number of patients who experienced
symptoms that required treatment, the number of
patients who withdrew because of gastrointestinal
symptoms, the number of patients who experienced symptoms for at least 3 days, and the
number of patients who had diarrhea that required treatment. On the other hand, signicantly fewer of the patients who consumed the
FOS-containing product experienced constipation that required treatment than those who received the renal product without FOS. Thus, the
study showed indirectly that ingestion of as much
as 18.5 g of FOSs daily was well tolerated by adult
hemodialysis patients.

Physiologic Effects of FOSs

Fructooligosaccharides resist degradation by
human alimentary enzymes90 and pass intact
through the stomach and small intestine. Once
these compounds reach the colon, anaerobic bacteria ferment them to obtain energy and carbon
for their own growth (Fig 2). During the process,
bacteria also generate short-chain fatty acids (SCFAs) gas, and heat. As a result of the fermentation,
there is an increase in the concentration of bidobacteria in the large intestine,88,91 an increase
in calcium absorption,92 an increase in fecal
weight,93 a shortening of gastrointestinal transit
time,94 and a possible hypolipidemic effect.95
Other effects observed in animal models include
(1) an increase in cecal weight96 because of the
increased availability of energy in the form of
SCFAs for the gut wall and (2) an increase in fecal
nitrogen excretion97 because of the additional
capture of ammonia nitrogen as microbial mass
and increased excretion of colonic bacteria in the
feces. The increased numbers of biobacteria in

Figure 2. Fermentation of carbohydrates by colonic bacteria. Fermentation results in the production of SCFAs, bacteria cell growth, gas, and heat.

82

JOMAY CHOW

the colon have been assumed to positively benet

human health through a number of mechanisms6
including (1) the production of strong acids98 and
other inhibitory substances99,100 that inhibit the
growth of potential pathogens, (2) the lowering
blood ammonia levels by protonating ammonia
in the colon,101 and (3) the production of vitamins102 and digestive enzymes.103

Potential Application for Renal

Patients
In populations that are frequently affected by
diabetes, such as the end-stage renal disease population, FOSs could potentially serve as a sugar
substitute. FOSs have 40% of the sweetness of
sucrose, and they have no unpleasant aftertaste.
Because FOSs are neither digested nor absorbed
in the small intestine, their ingestion does not
elevate blood glucose levels.104 In addition, FOSs
contain only 40% of the caloric content of hexoses (glucose or fructose) on a gram-for-gram
basis (1.5 kcal/g for fructans v 3.9 kcal/g for
hexoses105).
Chronic constipation is a common problem
among the dialysis population,106-109 with an
estimated 40%108 to 71% of patients110 affected
by this gastrointestinal disorder. The magnitude
of the problem is not surprising given that this
patient population carries many of the risk factors
associated with constipation such as uremia, electrolyte imbalances, and restricted water intake.111
In addition, the advanced age of these patients,
inactivity, and comorbid conditions such as diabetes mellitus and cardiac disease adversely affect
bowel function.111 The administration of multiple medications including iron supplements, calcium- or aluminum-containing phosphate binders, and opioids and the dietary restrictions
imposed on dialysis patients likely contribute to
the problem.
FOSs could potentially serve to alleviate constipation in the dialysis population.112-116 The
mechanism by which FOSs is thought to alleviate
constipation is likely to be similar to that of
lactulose and sugar alcohols.116 If the rate at
which these undigested compounds enter the
colon exceeds the colonic capacity to ferment
them, excess molecules create an osmotic effect
and draw water into the colon. In turn, the water
drawn into the colon acts to soften stools. Moreover, because 30% of wet fecal weight is made up
of bacteria,117 these compounds may also increase

stool weight by supplying energy and carbon for

bacterial growth. However, unlike lactulose and
sugar alcohols, the severity of side effects associated with ingestion of FOSs, such as abdominal
cramping, should be signicantly less because of
its lower osmolarity on a weight-to-weight
basis.116
Despite the presence of bacterial overgrowth
in the small bowel of patients with chronic renal
failure, FOSs would still likely reach the colon
fully intact. Although the bacterial species present
in small bowel bacterial overgrowth aspirates are
similar if not identical to those found in the
colon,118 the mean concentration of bacteria in
small bowel bacterial overgrowth is only 108
organisms per milliliter (v 102 colony-forming
units per milliliter in healthy humans119), whereas
the concentration of bacteria in the colon often
exceeds 1011 colony-forming units/mL. Thus,
the concentration of bacteria in the colon would
be at least 1,000 times greater than that in the
small bowel. Consequently, fermentation should
occur at a much slower rate in the small bowel
than in the colon, even in small bowel bacterial
overgrowth.

Products Containing FOSs

In Japan, where FOSs have been ofcially
recognized as a food for Specied Health use
by the government, FOSs have been incorporated into numerous products including candies, beverages, and even infant formula. In
contrast, the use of FOSs in the United States
has been primarily limited to dietary supplements in which it frequently appears in combination with probiotics because of the belief
that a mixture of these 2 ingredients would
benet the host by improving the survival and
the implantation of live microbial dietary supplements in the gastrointestinal tract, by selectively stimulating the growth and/or by activating the metabolism of one or a limited
number of health-promoting bacteria, and thus
improving host welfare.5 Only during the last
several years have FOSs started to appear in
food products. For example, inulin, a longchain fructan polymer, was recently added
to a commercial yogurt (Stonyeld Farm,
Manchester, NH), and NutraFlora FOS has
been added to a number of liquid nutritional
formulas including 1 intended for use in people
with end-stage renal disease.

PROBIOTICS AND PREBIOTICS

Conclusions
Probiotics and FOSs could potentially provide
several benets to renal patients. As an example,
probiotics may reduce the levels of certain toxic
compounds generated by the small bowel ora
that are thought to contribute to some of the
neurologic symptoms of uremia. On the other
hand, FOSs, which also happen to have a very
low glycemic index and lower energy content
than glucose or fructose, could potentially function in the capacity of a dietary ber supplement
to help maintain regularity in this patient population or as a reduced calorie sweetener for diabetic patients.

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